CIHM 
Microfiche 
Series 
({Monographs) 


ICIMH 

Collection  de 
microfiches 
(monographles) 


Canadian  Initituta  for  Historical  Microraproductions  /  Institut  Canadian  da  microraproductions  historiquas 


.'^mk  '^--^^-^L-^^^ 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


Tht  tnstitutt  has  attempted  to  obtain  tha  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographicaliy  unique,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


D 
D 

n 


Coloured  covers  / 
Couverture  de  couleur 

Covers  dan^ged  / 
Couverture  endommag^e 

Covers  restored  and/or  laminated  / 
Couverture  restaur^e  et/ou  pellicul^e 

Cover  title  missing  /  Le  titre  de  couverture  manque 

Coloured  maps  /  Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  en  couleur 


I    A   Bound  with  other  material  / 


D 


D 


Relid  avep  d'autres  documents 

Only  edition  available  / 
Seule  Edition  disponibte 

Tight  binding  may  cause  shadows  or  distortion  along 
interior  margin  /  La  reliure  serrSe  peut  causer  de 
I'ombre  ou  de  la  distrrsion  le  long  de  la  marge 
int^rieure. 

Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  II  se  peut  que  certaines  pages 
blanches  ajout^es  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  lorsque  cela  4tait 
possible,  ces  pages  n'ont  pas  4t^  film^es. 

Additional  comments  / 
Commentaires  suppl^mentaires: 


L'Institut  a  microfilm^  le  meilleur  exemplaire  qu'il  lui  a 
M  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  peut-Atrc  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvcnt  nxxJifier  uno  image  reproduite, 
ou  qui  peuvent  exiger  une  modification  dans  la  m^tho- 
de  normale  de  filmage  sont  indiqu^s  ci-dessous. 

I     j  Coloured  pages  /  Pages  de  couleur 

I I  Pages  damaged  /  Pages  endommag^es 


D 


Pages  restored  and/or  laminated  / 
Pages  restaur^es  et/ou  pelliculdes 


0  Pages  discoloured,  stained  or  foxed  / 
Pages  dteolories,  tachetdes  ou  piqu^es 

I     I  Pages  detached  /  Pages  d^tach^es 

[y/]  Showthrough  /  Transparence 

□  Quality  of  print  varies  / 
Qualit^  in^gale  de  I'impression 


Includes  supplementary  material  / 
Comprend  du  materiel  suppl^mentaire 

Pages  wholly  or  partially  obscured  by  errata  slips, 
tissues,  etc.,  have  been  refilmed  to  ensure  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  &\6  film^es  h  nouveau  de  fa^on  k 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
discctourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
film^es  deux  fois  afin  d'obtenir  la  meilleure  image 
possible. 


D 


D 


This  item  is  filmed  at  the  reduction  ratio  chectced  below  / 

Ce  document  est  film<  au  taux  de  riduction  indiqui  cl-dessous. 


lOx 

14x 

18x 

22x 

26x 

30x 

V 

1 

1 

. 

12x 


16x 


20x 


24x 


28x 


32x 


The  copy  filmtd  h«r«  has  b—n  reproduced  thanks 
to  tho  gortorotity  of: 

Special  Cellactlont, 
O.B.  ■•14on  Library, 
University  ef  ■•■tem  Ontario 

The  images  appearing  here  are  the  beet  quality 
poealble  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


L'eiemplaire  filmi  (ut  reproduit  grics  A  la 
g*n4ro8it4  da: 

Special  Callactlons, 
D.B.  Maldon  Library, 
University  of  Nastern  Ontario 

Les  Imeges  suivantes  ont  4t*  reproduites  svec  te 
plus  grand  soin.  compte  tenu  de  la  condition  et 
de  la  nettetA  de  rexemplaire  filmA.  et  en 
conformlt*  avec  les  conditions  du  contrst  de 
filmage. 


Original  copies  in  printed  paper  coyera  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  imprae* 
sion.  or  the  back  cover  when  eppropriate.  All 
otner  original  copiea  »t9  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


Les  exemplairee  origineux  dont  la  couverture  en 
pepier  est  imprim4e  sont  fiimis  en  commencant 
par  le  premier  plat  et  en  terminent  sott  par  la 
derniire  page  qui  compone  une  empreinte 
d'impression  ou  d'iilustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
origineux  sont  film*s  en  commencant  par  la 
premiAre  pege  qui  comporte  une  empreinte 
d'impression  ou  d'iilustration  et  en  terminant  par 
la  derniire  page  qui  comporte  une  telle 
empreinte. 


The  last  recorded  frame  on  eech  microfiche 
shell  contain  the  symbol  -^  (meaning  "CON- 
TINUED "K  or  the  symbol  y  (meaning  "END  "). 
whichever  applies. 


Un  dee  symboles  suivants  spparaitra  tur  la 
derniAre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbols  <-^  signifie  "A  SUIVRE".  le 
symbols  ▼  signifie  "FIN". 


Maps,  plates,  chsrts,  etc.,  may  be  filmed  at 
different  reduction  retios.  Those  too  large  to  be 
entirely  included  in  one  exposure  ere  filmed 
beginning  in  the  upper  left  hend  corner,  left  to 
right  end  top  to  bottom,  ss  many  frames  ss 
rsquired.  The  following  diagrams  illustrats  the 
method: 


Les  cartes,  plenches.  tableaux,  etc..  peuvent  Atre 
fiimAs  A  dss  taux  de  reduction  diffirents. 
Lorsque  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  clichA.  il  est  filma  A  partir 
de  I'angle  supArieur  gauche,  de  gauche  A  droits, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'imeges  nAcessaire.  Les  diagrammes  suivants 
illustrent  la  mAthoda. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

.:'3Sr55gK^. 


K2^^S. 


MKROCOfV   nSOlUTIOM   THT  CHART 

(ANSI  and  ISO  TEST  CHART  No    2l 


^     /APPLIED  \M/V3E     Ine 


16b J    tost    Mqi    St'««' 

l^OCHest^r.    h9m    fork  I  •609         JSA 

I '16)    *82  -  C300  -  Phon« 

("6)   208  -  ^69  -  Fa» 


49162 


THE  NEW  PUBUC  HEALTH 


The  New  Pnblic  Health  aod  Tabcrculosis 


B> 


II   W   Hill.  M    li.  M    1).  I)   I'   n 


lONDON.  ONTAKIII,  CANADA 


Reprinted   from 

THE  JOURNAL.LANCET 


February   1,  1915 


[Thl»  1h  r  reprint  of  the  tenth  paper  In  a  series  of 
ten  or  twelve  articles  now  appearlPK  In  The  Journal- 
Ljincet  upon  the  subject  of  "The  New  Public  Health." 
Additional  copies  of  this  reprint  and  of  the  entire 
series,  as  thev  are  published,  mav  be  had  upon  applica- 
tion to  the  Minnesota  State   Board  of  Health.  St.  Paul.] 


^ 


rm-:  mav  itiuk   ukai.tii 

TKNTH  I'AI'KK 
I  MK  NKW  I'l'HI.IC  HKAI.IM  AND   ll'HI  K(  ll.oMS 

F!v  II.  W    llii.i.,  Ml'..  M  I),.  I)  I'.ll 

l>lr>'ii<ir.    IiiHtltiiti-    uf    I'lililli     lli'iilili.    I.<in<lori.    iini 
I.iitf     liliHi'liir.     I>lvl>.(uii    iif     i:|il.l.iii|iil..i;\  .     Mliiii. -Mill 
Sluli-   Hiiar.l   ut   Ihiiltli 

Previous  artuU'-^  have  oiitliiinl  tlu-  m'lH-rai 
principles  wliieli  nuverii  iiiiniern  ptihlii-  liealtli 
efforts,  riie  jiresent  article  will  vlmw  tlie  >.pecitii 
applications  of  these  i)rinci]iles  to  one  specilic  in- 
fectious disease,  namely,  tulierculosi-.  Tliis  di- 
ease  is  selected  liecausc  the  same  princiiiles  that 
apply  to  all  other  infectious  diseases  apply  In  it 
ami  hccausc  it  is  the  most  imiiortant  of  all  the 
diseases  now  reco>j;nize<l  as  really  prcvcitlal<li\ 
with  the  possihle  exception  of  the  venereal  ili^- 
eascs. 

Tuherculosis.  of  all  forms,  is  due  to  the  i;ro\\  tli. 
somewhere  in  the  Ixidy.  of  a  certain  yerm.  ex- 
actly as  diphtheria  and  tyjihoid  are  due  to  the 
Rrowth,  in  the  iMxIy.  of  certain  kit"'^  There 
are  many  very  definite  individual  differences,  in 
the  size,  shape,  manner  of  growth,  etc.,  of  the 
three  different  tjerms  of  these  three  differeiu  dis- 
eases, and  these  differences  make  it  perfect!)  |«)-- 
sihle  tn  distinijuish  each  tjerm  from  the  others, 
just  as  any  farmer  can  distintiuish  oats,  corn, 
and  potatoes  from  each  other. 

I'ut   just   as   there   are    different    \ arietie*    of 
potatoes,  so  there  are  at  least  tw<>  varieties  of 


ii 


tiOKTciiloiii*  Kcriiii  wliuh  affect  luiinari  UinKs. 
One  variety  it  what  it  known  a-*  thf  human  tu- 
fwrciilotit  nvnu  pro|>rr  lln-  ..ilur  ii  fi»iin<l 
chiefly  in  cattlt-  and  i'.  ihcrtl'.irr  lallnl  the  cattle 
t»l)crcnlo<iis  uerm  (the  bovine  tul»erculr«it 
Ktrnii.  and  this  name  ii  nhtn  t<»  this  variety 
even  when  it  i>  found  in  tlie  human.  a>  it  -.ome- 
timet  it. 

Ill   MAN     Tl  IIKK(  I   KISIS 

A  motf  im|Kirfant  ilifTercnce  that  the  nernit  of 
human  tubcrculoti*.  of  (hphtheria,  and  of  tvphoid 
fever  slwiw  anioncst  tlieniselvet  is  not  a  differ- 
ence in  size,  shape,  etc  .  hut  in  the  parts  ,,f  the 
t)f>dy  each  selects.  Thus  the  di|>htheria  yerm 
flourishes  chietlv  in  the  nose  ami  throat,  and  the 
typhoid  KPrm  flourishes  chiefly  in  the  intestine 
and  perhaps  the  blood;  while  the  human  tut>er- 
culosis  Kcrin  will  flourish  almost  anywhere  in 
the  body,  K'-inds,  bones,  joints,  intestine,  kidney, 
brain,  lungs.  This  selection  is  no  mere  accident, 
although  \vc  do  not  know  how  it  comes  alK)Ut. 
.Ml  tliree  serins  enter  the  lK)dy  chiefly  by  the 
mouth,  conveyed  thereto  diiefly  by  tlie  futtuix. 
but  also  more  or  less  through  food  and  milk.  and. 
in  rhc  case  of  tyjihoid  fever,  through  water  and 
flics.  On  entering  the  mouth,  all  three  germs, 
which  are  of  course  far  too  small  to  taste  or  feel, 
are  swnllowed  in  the  fiKxl,  milk,  etc.,  in  which 
they  happen  to  l)e  present,  or  merely  in  the  saliva, 
if,  as  is  most  usual,  they  reach  the  mouth  di- 
rectly or  indirectly  from  the  fingers.  ( )nce  swal- 
lowed, all  three  pass  into  the  stomach,  where 
many  arc  killed  by  the  acid  there  present,  the 
•survivors,  if  any,  passing  on  into  the  intestine. 
On  the  journey  from  mouth  to  intestine,  some 
arc  left,  of  course,  by  the  wayside,  stranded  on 
the  tonsils,  thr  at.  gullet,  etc.     Here  at  once  i- 


thn^n  tHrir  rr"«|»rrtt\r  iH-iiiliaritu""  <  »f  all  the 
diphtheria  ucrttH  that  arc  thu<  •.walkivviMl,  pra»- 
ticalty  onlv  thoM?  that  arr  otraixlnl  in  thrthmat. 
will  llotirith ;  iIhho  diphthrria  Ktmi'*  which  fta" 
on  into  the  stomach  <ir  intr>ttnc  arc  ilcslroycd 
i>r  |>aHS  out  harmlri<<l\.  (  >m  the  other  hand.  t\- 
phoid  Ki^rni^,  if  •<trandcii  <iti  the  throat,  do  n<>t 
tloiiri-.h  there,  nor  do  tlnoe  which  reach  the 
Htxniach  tlonri^h  in  that  uruan.  It  i^  only  tho-c 
t>Iihoid  Ker  n>  which  lurvive  the  joiirtiey  untd 
the  intestine  is  entered  that  can  succeed  in  pm- 
ilncinj,'  typhoid  fe\er.  i'he  Innnan  lulK'rcn|i»»i« 
K'ernj  has  a  still  longer  road  to  yrn.  Not  onl\ 
nni-t  it  ,  ass  itionth.  stomach,  and  intestine,  hut 
it  mu-t  lie  also  ahsoriicd  from  the  intestine  into 
the  hIcKid,  as  the  food  is;  hut  it  does  not  ^fow  in 
the  hIcKxI.  The  hl<M»d  is  only  a  river,  hy  which 
it  can  Ik-  carried  to  a  favorable  dcvelopini: 
ground.  \\c  tlo  not  know  at  all  why  human 
tul»erculosi>  ycrms  enterinj;  tiic  hUxxl  tlui». 
should  elect  to  settle  an<l  nmw  in  a  joint  in  one 
person,  in  a  lunjf  in  another,  in  a  kidney  or  a 
i;land  or  a  Ixme  in  anotiier.  However,  this  is  the 
way  in  which  these  different  forms  of  human 
tuberculosis  develop.  The  old  idea  that  human 
tuberculosis  of  the  lunjj  (^consumptioti )  is  con- 
tracted chiefly  by  breathing  the  yerms  directly 
into  the  lunns,  has  been  definitely  upset.  The 
lunKS  are  infected  from  the  bkxi<l-stream  chictly. 
just  as  are  the  other  internal  organs,  bones,  and 
joints. 

Another  an<l,  from  the  public  health  stanil- 
jwiint,  an  even  more  important  ditTerence  exist>. 
Diphtheria  gemis  developinn  in  the  throat,  and 
typhoid  fever  K«^rms  develo|)in>:  in  the  intestine, 
can  readily  escape  from  the  body;  in  the  ca-'e  of 
diphtheria,    throURh    the    mouth    and    nose    dis- 


-luryc,    III   ihr  ,a.r  nf   ^^|,|„M.|    ivsvr   thr..iii;li 
Ifw  f«mcl.  an.l  ...inriiin.-,  H,,.  hb.l.Ur,  .li..  Inri-,-, 
le  i-  the  rvalK-  (.V  lh«'^r  .  hitnnrU  of  tlir,r  i-rrriu 
lr..m    ilir     Ih«|v     whuh    ijwkr*    thr^r    .|i„iiM» 
•.auhiny"   ,>r    ••iiifr.ti..ii,-    „r   "o.uiiminu.il.k-  • 
l..r  If  il.cv  ...ul.l  „..t  rM.,|.c  from  th.-  UnIx   tluv 
.'..u.     n-l     rradi    ..thrr    (ktm.,,.     .ui.|    llu-rvfurr 
.•.ul.l  Hot  U-    •.-at.liitiK  ••     Cut   in   human  »ul.rr. 
■■•«I..M^.  m..M  nf  tlu-  plaic,  wlurr  ,.  .U-vrl.,,,, 
iM.nrv   Klan.lv    ,.„nt,.   vU  ,       arv   n..t   .nmuv.r.l 
uith  anv  ..ponun;  ..f  the  |m„|v  j,,.  „|,„.,,  „,^.  ^^.^^^^^ 
mav  l.-axr  tlu-  »M<h      Tlioc  f.,rm*  .,f  tulH-nul.,,,. 
haw  n.i  Krrat  hiKlmav    t..  the  ..ut,i.|,-   Ivinu  at 
their  .|.»,r.  I.,  carrv  ilir  ^rrms  ,,iit  t,,  utlu-r  |«t- 
"•I'v     I'raitualiv  oniv  in  human  tulK•rall..^j,  „( 
•lio   hiUK,  arc-  Midi   hiKluva>,  pn.vi.jr.l    f„r   the 
.utnau  tulK-r.ul..Hi,  i;,.r,„..  althnu^rh  ...im-tiiiu-s  in 
Ma.l.kr.  ki.liivv.  an.l  mt.-Mi,ial  tulK-nuj,,,!,      Mut 
u>  the  iattir  f..rm..  the  uerms  ,|o  not.  an  a  rule 
pasN  out  hv  the  hiuhwavs  pn.vi.le.l  for  them  in 
'Udi  cn.htion  or  smh  uuml^-rs  as  to  Iwof  .ori.nis 
miiM.rtaiue  in  pn-panatin^'  the  c|i.ea^e.     I.i  human 
lunvr  tiiU-rouloMs,  .,n  the  other  hau.l.  the  win.l- 
pi|.f.  throat,  an.l  in.>utli   form  a  hiuhwav.  al.mi,' 
ulndi  the  uerms  may  eM'a|K-  from  the  affecte.l 
un^r  m  such  enorm..us  numU-rs  that  twentv-f.mr 
l""ion   (K-r  .lay   have  l^-en   .letette<l   in   the  rlin. 
••har^es  (sputum)   from  the  lunp  of  a  sin^'le  a.l- 
vanee.1  casr,  althnu^;!.  tlie  avcrajfe  numk-r  from 
ilu-  averaue  case  is  iHually  "onlv"   fo„r  or  five 
l»illi..n  daily. 

Thus  it  comes  alMnit  that  human  tuherculosis 
"f  the  lunfjs  ,<  the  only  o.mmon  form  nf  human 
tuherculosis  which  is  much  to  Ik;  feared  as  in- 
lirtn.us.  Practically  all  the  other  forms  r.f  hu 
man  tulH.rculr.si.  arc  .lerived  from  the  sputum 
"•    la^es    „i    human    hint;    tuherculosis,    carncl 


.  hulls  \f\  !i!MUt!i  -|>r.n  .mt!  ••!)  ilu-  fianih,  .itul  >.f 
lUM"'  >>i  lititiuui  liiii^  titU'rdilioM  iImI  tioi  .ut  III 
»|»rra«I  in(«Htn>n  ••>  i.tluT  ihtwhi*.  all  f'trm^  "if 
httiiuin  tutKTfnliis.v   wmi'  |  i|i-.i|i|H';tr 

\|i.r«'ti\«T,  «'\fii  liiiiinit  lurii;  liilH-riiilu'*!'.  i«  iint 
MTV  iiiii'i  tiiiti^  III  ilif  «'arK  ■'tas'i'*,  i  »•  ,  vxlu-nllif 
mrtii-.  ari'  ),'f"""ii;  m  tin-  Uiiik  Ji»mu',  (hu  liav*- 
ii'il  \vt  ri'a»lu-il  till-  air  |>a«'<ai;f'«,  In'tati*!'.  tttitii 
lln-n,  lltf  l;^rtll^  tamii)!  c-^tap«*  itito  thr  uiiii||ii|h- 
■iimI  ^<i  Ii\  itu-  lliriiat  In  llic  iiioiiiji  \\  lu-n  in  the 
lal«T  ■«lai;i"«  tin-  ^'crm-.  rtaifi  llu-  air-pa"ai;r".  tlir 
*\a\    ii>t  llif  i>ta|>f  111   tlir  i;irm>.   lo  tlu'  ..iit-ulf 

•  liul     »<i    lo    iitluT    tlliitlllw    l>    "m|H-M  "        iVr-.nll'.    Ill 

llii*  tlanf  <if  liilHrnilii-n  arr  falKil  "<i|»rti  '  la-n'-, 
ami  It  i-<  ilnrcfiirf  <.nK  tlif  ""Hkii"  »a>T'>  iliat  ari- 
-truuiNlv  l<i  Ik-  ffarn!  a>  ii\f«'>  Ikhi'. 

till      MliilllloN    (iK   t    \lllf     11   lihHi  I   liisl-,    i\    mi- 
lt t  \i  \\ 
Alllioimli   tlu-  laltif  iiiIktviiIii^is  ^jirm   <litTfr- 
In  nil  llu'  liuinan  liilitri  ulnsjs  ucrtn  Hnim-wliat  in 
>i/f.  ^iiajH,  ill-  .  llu-  iiKisi  iiniMirlanl  pulilic  litallli 

•  lillfirtiicc  Is  ihis;  tlif  r«|lk-  luUrr»i!iisi>  (,'orm 
scliloni  prodiUfK  lutiij  tulicrculosis  m  tin-  human. 
It  prodiuis  iKiiif,  ylanil,  juittf,  itf  .  tulKTculusis, 
hut  h\\\K  tiilKTriilosis  hardlv  fvtr,  l'i>n>iiUT  hi>\v 
inilMiriant  tln<.  fact  is.  It  nieans  that  cattle  In- 
hi'iiiilosKi  rxistini;  in  a  hutnaii  tan  iwry  sclilum 
he  conveyed  from  that  humtin  to  another  human. 
In  (ilhiT  W'iriU.  ratlU*  tiilivrculo-is  tiiav  liv  traiis- 
inittfii  fpiiii  cattle  to  man,  hut  practualiv  is  not 
furthi-r  transiiiittc"!  frimi  man  to  man.  In  prc- 
vont  c.-.ltic  tiihtTcnlosis  in  the  hiiman.  we  dn  not 
need  In  take  into  account  exisfinjj;  casi-s  of  cattle 
tiihercniosis  in  the  hmiian.  hut  only  •.•xistiny  cases 
of  catiie  tulKTculnsis  in  cattle.  If  we  free  <Hir 
cattle  of  callli'  tnlKTcnlosis,  wt-  shall  free  our 
Imtnans  of  cattle  tiihercniosis  also;  aiul  this  is  the 


I 


only  practical  way  that  cattle  tiiherculosi",  in  the 
human  can  lie  alKilished  unless  and  until  the  hu- 
man race  abanclons  the  use  of  raw  co-v's  miik. 

Till-    ABOLITION    (.1-    Ml  MAN    TinERCUI.OSIS 

How  can  we  abolisli  human  tufwrculosis^    I-'x- 
act  y  as  we  can,  and  .s„„,e  day  shall,  abolish  anv 
and  all  other  infectious  diseases,  bv  killinp  off 
the  irerm  that  causes  it.  exactlv  as  we  have  al- 
most abolished  the  race  of  buffalo  bv  killing  off 
the  existinR  buffalo.    We  know  well  eiiouKb  that 
when  t  c  last  buffalo  is  dead,  no  man.  however 
wise,  no  >jovernnient.  however  powerful,  could 
ever  pnHliice  another  buffalo.     So     .nee  tlic  e\- 
istinfi  <liphtheria  or  scarlet  fever  or  tuberculosi, 
perms  are  all  dead,  there  is  no  wav  under  heaven 
by  w  iich  these  particular  jrerms  could  !,<    pro- 
duced ajfaiii.     Those  which  exi^t   now  are  not 
evolved  from  dirt  any  more  tliai.  ,.re  buiTalo  or 
roses      I  hose  which  are  livinjj  todav  are  >implv 
the  descendants  of  those  which  existed  ^c^ter- 
day  and  so  on.  just  as  in  the  case  of  buffalo  or 
roses,  back  to  the  dawn  of  history.     Once  anv 
race  or  plant  or  animal  is  wiped  out.  it  can  never 
be  redeveloped;  and  the  tuberculosis  frerm,  just 
as  well  as  the  Rerms  of  diphtheria  or  tvphoi(' 
fever,   can   be   alMilished   exactlv   as   the  'mega- 
therium or  dinosau.  has  been  alx.lished,  i.  e..  bv 
the  killuiR:  of  the  existing  individuals. 

"But  consider  the  enormous  numbers  and  the 
tiny  size  of  perms  and    that  thev   are  present 
cvery.i'here~m  air.  water,  food,  milk,  dust  •  in 
and  on  everything  we  touch  or  taste  or  handle 
It  IS  quite  impossible  to  kill  them  all." 

True,  ^cnns  are  everywhere  but  >wt  disease 
.s:enns.    We  know  some  fifteen  hundred  or  more 
species  of  jjerms  and  hardiv  fiftv  of  these  pro- 
duce disease,  while  only  two,  already  mentioned, 
8 


produce  tuberculosis  in  the  human.  I  hat  these 
arc  very  small  and  cannot  he  slaujjhtered  indi- 
vidually like  buffalo,  is  true,  but  it  is  also  true 
that  their  very  minuteness  means  that  billions  can 
be  slaughtered  in  one  operation,  if  they  are  only 
kept  together.  As  to  tuberculosis  germs  being 
everywhere,  all  over,  out<l(K)rs  and  indixirs — thi:; 
is  not  true.  \o  more  important  f'  t  in  public 
health  has  ever  been  formulated  than  this,  due 
to  that  keen  leader  in  public  health,  Chapin  of 
Providence:  l/ie  };i'rms  that  produce  disease 
are  not  ubi(iuitous,  not  in  dust  everywhere,  water 
everywhere,  milk  everywhere.  They  are  chietlv, 
almost  wholly,  in  the  bodies  of  a  few  (relatisely) 
IH-'ople,  or  animals;  and  when  they  escape  from 
those  bodies,  where  alone  they  find  the  peculiar 
food,  high  temperature,  abundant  moisture,  and 
darkness  which  they  need,  they  promptly  die  or 
become  harmless.  Even  in  water,  milk.  food, 
etc.,  into  which  they  may  be  introduced  from  in- 
fected persons,  their  lives  are  short,  and  thev 
must  quickly  reach  a  new  living  victim,  or  die. 

To  alwlish  any  one  race  of  disease  germs  is 
far  easier  than  to  destroy  some  much  larger 
things.  Thus  to  abolish  t1ies  means  not  only  kill- 
ing all  flies,  indoors  in  all  houses  everywhere,  in 
all  stables  everywhere,  in  and  around  all  dwell- 
ings everywhere,  but  al.so  throughout  all  fields 
and  forests,  mountains  and  valleys  everywhere, 
because  flies  are  hardy  outtloor  beings  as  well  as 
indoor  beings.  They  can  breed  and  flourish  al- 
most anywhere,  where  any  kind  of  food,  even  in 
vanishing  quantity,  is  to  be  had.  Moreover,  thev 
can  move  of  their  own  volition  with  promptness 
and  despatch,  have  quick  eyes  antl  quicker  w  ings 
to  escape  designing  enemies,  and  in  a  thousand 
wavs  can  take  care  of  themselves. 


^m 


Disease  K't-rms,    in   contrast   with  the  »ly.  are 
very  liny  and  helpless  particles  of  protoplasm, 
having  no  eyes  to  see  an  enemy,  no  nose  to  smell 
hmi.  no  means  of  rnnninj,'  awav  from  him.     Thev 
cannot  nourish  on  almost  anv  "food,  but  need  the 
living:  tissues  "i  the  human  hoily ;  thev  cannot  prow 
at  almost  any  temperature,  but  must  have  the 
heat  of  the  human  body.     In  brief,  thev  are  not 
merely  indoor  plants:  they  are  incubator  plants 
and  cannot  jrrow.  thrive,  or  reproduce  themselves 
in  nature,  except  in  the  incubators— our  iM.dies. 
or.  in  a  few  cases,  animal  bodies.  ,,nnide  them' 
llence  It  we  were  able  to  take  a  visual  census  of 
all  the  hviUK  tuberculosis  or  scarlet  fever  or  diph 
th-ria  fjcrms  in  the  world  we  should  see  them 
not    m    the   dust   everywhere,    the   water   everv- 
whcre.  the  food  everywhere,  etc..  but  in  a  verv 
few  place>  only,  and  those  places  would  be    in 
almost  all  cases,  the  bodies  of  humans   (or  ani- 
mals). 

Indeed,   we  can    iV.retell   just  about   what   the 
census  (.f  tuberculosis  perms  in    Minnes.ita    or 
in  any  other  district  of  the  temperate  zone,  would 
show.     It  would  show  about  one  person  in  every 
seven  hundred  of  the  jxipulation  carrying  a  large 
number  of  active,  living,  growing  germs  in  the 
lungs.— germs  that  were  escaping  to  the  outside 
and  reaching  other  persons'  mouths.      It  would 
show  also  a  number  of  other  persons  in  whom 
the  germs  were  present  in  joints,  bones.  ;;lands. 
etc..  but  not  escaping   to  others;  and   it  would 
show  a  number  of  persons  affected  in  the  lun.'s 
and.  later,  likely  to  develop  to  the  point  whe're 
the  germs  onild  escape,  but  practically  harmless 
to  others  .so  far.     Beyond  thi.s.  hunt  high,  hunt 
low.  search  garbage  barrels,  manure  heaps,  dead 
animals,    dusty    streets,    sewage,    water,    foods. 


10 


milk,  etc..  and  linnian  tiiJ)erciil()sis  gcrm>,  alive, 
•.Towintj,  capable  of  pnxjncin),'  tlic  (li>iea>e.  Ti-okA/ 
not  he  found,  rriie,  in  the  immediate  neijjlihor- 
li<K)d  of  the  "open"  cases  the  sputum  thev  throw 
out,  their  mouth-spray,  and  their  hands  would 
show  the  ffcrms,  and  thinji^  they  spit  into,  mouth- 
spray  into,  or  touch,  would  show  for  a  short  time 
a  few;  hut  these  would  he  dyinjj  or  already  dead, 
holdinj,'  out  dantrer  to  other  jiersons  onlv  durini,' 
tlie  short  time  which  elapses  hetween  leavinj,' 
their  happy  homes  in  the  human  luni;  and  death 
outside  from  starvation  and  dryinj,'.  This  ap- 
plies, not  to  tuberculosis  ^erms  alone,  but  prac- 
tically to  all  the  germs  of  the  or<linar\  mfectious 
diseases,  anthrax  and  tetanus  forming;  two  chief 
exceptions,  both  rare  diseases  here. 

So  person  ciiertictic  cnoui^li  to  advocutc  tlir 
abolition  of  flics  should  hrsitati'  a  moment  to  ad- 
vocate the  far  simpler,  smaller,  ea'ier,  and  far 
more  important  'n'ork  of  aholishini^  the  !:;erms 
that  alone  can  make  the  fly  a  dani:;er. 

In  brief,  the  method,  and,  I  believe,  the  only 
rapid.  coni])lete,  effectual  method  of  abolishing 
human  tuberculosis,  is  this;  find  the  "open'  cases 
and  prevent  the  spread  from  tliem  of  the  j„'erms 
thev  alone  throw  out  in  numbers  and  condition 
to  be  feared.  That  means,  find  the  one  person 
in  every  seven  hundred  whose  infection  threatens 
all  the  rest,  and  supervise  him  just  enough  to 
keei>  his  discliarges  from  entering  other  people's 
mouths. 

How  is  this  one  person  in  every  seven  hundred 
to  be  found?  Xot  without  hunting,  not  without 
ingenious,  skillful,  deliberate,  sagacious,  well 
trained  hunters,  epitlemiologists  as  devoted  and 
l)ersistent  in  their  work  as  the  average  insurance 
agent  is  in  his, — men  who  devote  themselves  to 

II 


the  atmlition  of  tuberculosis  as  whole-heartedly 
as  any  merchant  does  to  niakinj,'  money. 

.\n<l  how?  Where  shall  we  hcRin?  Must  wo 
canvass  the  whole  |K)puL,  t  one  by  one?  True, 
that  would  do  it,  hut  epidemiology  has  found  a 
simpler,  keener,  more  scientific,  far  more  eco- 
nomic |)lan.  illustrate<l  for  typhoid  fever  in  a 
|)revious  article  of  this  series  (  So.  3  ).  Hefiin  with 
the  known  cases  and  search  the  zones  of  infec- 
tion surroundinjj  each  for  mild,  unrecognized, 
and  concealed  cases.  ( In  tulwrculosis  the  search 
for  carriers  is  probably  unnecessarv,  certainly  at 
the  present  time. ) 

"liut  why  not  concentrate  on  the  incipient  lunj; 
case,  the  case  iiiat  may  l)e  cured,  and  by  prevent- 
mp  this  case  from  Roinj;  on  to  the  "open"  in- 
fectious stage  get  ri.l  of  danger  to  others  thus, 
nistead  of  by  attention  to  the  open  case?"  For 
several  reasons,  the  alit.Iition  of  tuberculosis 
through  care  of  incipient  lung  cases  onlv  cannot 
at  present  be  accomplished  : 

1st.  P.ecause  incipient  cases,  in  the  truly  in- 
cipi-;nt  "non-open"  stage,  are  discovered, 'i)er- 
haps  are  di.scoverable.  in  a  verv  small  percentage 
only  of  their  total  number. 

2nd.  P.ecause  a  large  proportion  of  the  in- 
cipients  so  found  would  not  go  on  in  any  case. 
whether  found  or  not.  to  the  open  stage;  ancl 
the  time  and  money  and  efforts  spent  in  finding 
and  supervising  them  would  have  been  relatively 
wasted. 

3rd.  P.ecause  a  certain  ptoportion  of  the  in- 
cipients  so  found  :could  go  on,  •«  any  case,  to  the 
open  stage,  and  thus  become  nfectious'  cases, 
despite  all  efforts.  In  these  alon,.  would  the  ef- 
forts expended  I)e  of  service  in  preventing  new 
cases.    The  troub'e  is  that,  in  the  incipient  stage, 

12 


it  could  not  1)C  ilctcrniiiiccl  wlictlicr  or  not  the 
case  would  so  develop. 

4th.  fiei-ause  the  time  and  attention  devoted 
to  incipients,  to  prevent  them  Iwcoming  open 
cases,  would  imply,  as  it  has,  alas,  so  far  im- 
plied, nejjlect  of  the  advanced  "ojw-n"  cases,  in 
which  the  danger  of  infection  is  so  immensely 
Rrcater. 

5th.  Because  if  all  the  incipient  cases  were 
discovered  they  would  form  a  mass  of  persons 
so  great  as  to  be  beyond  handling  properly  by 
any  at  present  even  dreamed  v)f  force  of  attend- 
ants, etc.  If,  as  at  present,  only  a  very  small 
projwrtion  were  found  the  actual  situation  would 
not  be  materially  changed. 

"Would  you  then  cease  the  care  of  incipient 
cases  in  sanatoria,  such  as  that  at  Walker.  Minn., 
and  concentrate  wholly  on  the  advanced  case?" 

No.  I'irst.  because  the  tuberculosis  sanatoria,  in- 
tended though  they  are  for  incipient  cases,  really 
handle  very  many  "open"  cases,  and  to  that  ex- 
tent prevent  new  infections ;  secondly,  because 
the  tuberculosis  sanatoria  do,  in  a  measure,  fulfill 
their  proper  function  of  cure  for  incipients  and 
even  early  "open"  cases  to  some  extent  and  hence 
save  life.  Rut  as  a  means  of  abolishin}^  tubercu- 
losis, the  ordinary  tuberculosis  sanatorium  for 
incipient  cases  is  quite  hopeless. 

The  thing  to  do  first  is.  find  the  recognized 
"open"  cases,  whether  tiiey  be  in  early,  advanced, 
or  late  stages,  and  place  them  where  they  can 
spread  the  disease  no  further.  Then  search  the 
"zones  of  infection"  surrounding  them,  i.  e.,  their 
relafves  and  associates,  for  mild,  unrecognized 
or  concealed  cases,  and  also  for  incipients.  han- 
dling all  "open"  infectious  cases  thus  found,  in 
the  same  manner.     This  system  would  l)egin  at 


13 


the  rI^Jht  ciul  l)v  st.ii.piiijr  further  infections  an<! 
would  incidentally  find  those  earlv  "oiwn"  and 
"nnn-()|)^n"  incipient  ca>es  wherein  sanatorium 
treatment  would  lie  of  most  avail. 

SI   MMAKV 

i  uhirculosis  is  a  ty|)ica!  infectious  disease,  and 
It  must  l>e  handled  on  the  same  principles  as  any 
other  infectious  disease;  hence,  hv  hlfx-kinj;  the 
routes  of  infection,  I.ut  chiefly  hv  findinj,'  the 
sources  and  prevcntinj,'  spread  thence. 

<  »f  the  five  preat  routes  of  infection, —water, 
fo<"l.  Hies,  milk,  ami  contact,— human  tubercu- 
losis travels  chiefly  hy  contact,  through  sputum, 
mouth-spray,  and  hands,  directly,  or  almost  di- 
rectly, from  patient  to  prospective  patient.  Prac- 
tically, it  is  spread  exactly  as  scarlet  fever  or 
<li|)htheria  is  spread.  IHihlic  flies  and  public  food 
supplies  are  comi)arativelv  insijjnificant  convex- 
ors.  I'lihlic  water  supi)lies  are  almost  ne«li>,Mble, 
and  public  milk  supplies  act  chieflv  in  conveyinp 
cattle  tu!)erculosis  to  man.  althoujrh.  if  the  milk 
be  handle.l  by  tuberculons  humans,  it  may  con- 
vey human  tuberculosis  also. 

It  is  evident,  then,  that  blockinj,'  of  routes, 
"ince  the  chief  one  is  contact,  involves  chiefly  the 
far  more  important  measure  of  findinjr  the  source, 
jii-t  as  m  scarlet  fever,  or  diphtheria,  etc..  and 
if  these  sources  are  found  and  prevented  from 
access  to  the  routes,  the  routes  may  he  disre- 
,1,'arded.  The  measures  for  findinjj  "the  human 
sources,  practically  the  "open"  cases  of  lun^  tu- 
berculosis in  the  human,  are  epidcmioloRicai  and 
have  already  been  discussed  in  principle  l>efore 
(Article  3i 

The  measures  necessary  for  finding  the  animal 
sources    (infected    milch    cows)    are    the    well- 


knciwti  tiilKTcuIin  test  of  herds,  witli  pniiK-r  rc- 
(ictitidtis,  and  tin-  elimination  of  tlie  tu!)croulous 
animals  Serious  enoiiuli  as  cattle  tiiltcriiilosis 
in  the  human  is,  its  jirevalence.  nevertheless,  i< 
M)  nuuh  less  than  that  of  human  tuherculosis  and 
its  infei"ti\eness  in  the  human  is  so  nearly  nei;- 
li),nl)le.  if  our  eflforts  were  concentrated  wholly  on 
human  tuberculosis  more  case-*  and  more  fleaths 
would  l)c  prevented,  in  a  year's  work,  than  etTorts 
on  l)ovine  tuherculosis,  however  successful,  could 
()ossibly  achieve  in  many  year-.. 


IS 


